WA Health system

Goals of Patient Care

  • Goals of Patient Care is a clinical care planning process used during an admission to hospital or other care facility.
  • It helps to determine which treatments would be useful for you, if there was deterioration in your condition.
  • The Goals of Patient Care process uses a shared decision-making approach.
  • A conversation is held with you and where relevant, your family or carer(s) and is led by your hospital doctor.
  • Together, you decide which treatments would be appropriate and acceptable to you.

During an admission to hospital or a planned outpatient appointment, important Goals of Patient Care decisions are made in light of your current health, your individual health care needs, and your preferences regarding future care. You may also want to describe treatments that you would prefer not have. You will also be able to ask questions and hear the opinion of your treating clinician.

Having an open discussion about your Goals of Patient Care will enable your preferences for care to be discussed and your views heard.

Goals of Patient Care clinical documents

In Western Australia, the Goals of Patient Care process uses a clinical document to record information about the shared-decisions that have been made. This document is written by your healthcare team following the goals of care discussions between you, your doctor or health care team and your family or carer(s).

Discussing your goals of care

When you talk about your goals of care with your doctor or healthcare team, you should talk about your current health, your values and preferences. You may also wish to discuss any cultural, spiritual or religious considerations that you feel may impact your treatment choices. The healthcare team will share their knowledge about your condition or illness and what treatments might be helpful or unhelpful for you.

Goals of care discussions can help plan the type of treatment you would prefer if your condition deteriorates while you are in hospital. This might include emergency or life sustaining medical treatments that you may need in an emergency, for example, cardiopulmonary resuscitation (CPR) or admission to an Intensive Care Unit (ICU). These treatments may have implications and limitations in relation to your quality of life.

Tips for your goals of care discussions
  • Think about what is important to you. What is important about your daily life? For your care? What do you want to avoid or achieve?
  • Think about your goals for your health care. What is your medical condition? How might it change over time? What services and treatments might help you, which ones would you not want?
  • Invite your significant others / next of kin / carer or other to be there with you for the conversation.
  • Bring your Advance Health Directive or other advance care planning document with you if you have one.
Documenting your goals of care

There are four treatment options/goals of care that are recorded by your healthcare team on the Goals of Patient Care document. These only apply if your condition deteriorates.

  1. All life sustaining treatment
    All treatments including care within an ICU will be considered.

  2. Life extended intensive treatment – with treatment ceiling
    Care within an ICU will be considered but not all treatments will be used e.g. the person does not wish to have blood products.

  3. Active ward-based treatment – with symptoms and comfort care
    The persons treatment will be given within a hospital ward, their care will not be transferred to an Intensive Care Unit. There will be an emphasis on quality of life and on treatments that will improve comfort.

  4. Optimal comfort treatment – including care of the dying person
    The aim of all treatment will be to provide comfort and prevent and relieve suffering.

Once the Goals of Patient Care document is completed, it is usually kept in your bedside medical notes while you are in hospital, so other health care staff know what you have decided. A copy will be uploaded to the health service’s electronic health record if one is available. You may also be asked if you’re happy for it to be uploaded to your My Health Record (see section below called 'Goals of Patient Care and My Health Record).

You or your family can ask to see or discuss this document at any time.

Changing your mind and updating your document

Your goals of care are likely to change over time, especially as your health changes. You and your family/carer can ask to talk about your Goals of Patient Care document with your doctor at any time. The document can be changed and updated as your health changes.

If you have previously had a Goals of Patient Care document written and you are readmitted to hospital, you should discuss your goals of care again with your doctors and update it where necessary.

Goals of Patient Care and Advance Care Planning documents

Goals of Patient Care documents are not the same as advance care planning (ACP) documents for legal purposes. ACP documents are written by you and are covered by law.

If you have an ACP document, such as an Advance Health Directive or advance care plan, make sure your healthcare team are aware and have a copy in your medical records. A Goals of Patient Care document is still relevant and should align with your ACP document.

Goals of Patient Care and My Health Record

If you have a My Health Record (MHR), there are some WA Health hospitals that can upload your Goals of Patient Care documents to your record. This can only happen if you agree to this with the doctor at the time of completing the Goals of Patient Care. Having copies of your Goals of Patient Care document in MHR, allows it to be seen by healthcare professionals involved in your care and can inform ongoing discussions with you about future treatment and care.

If you get admitted to a different hospital, your new healthcare team may review your Goals of Patient Care document in MHR and use it to talk about your goals of care in your new admission.

Like many documents in MHR, you can remove a Goals of Patient Care document from your record at any time. For further information on how to do this visit My Health Record (external site).

You can also find more information about advance care planning on My Health Record (external site).


Last reviewed: 11-12-2020
Acknowledgements

WA Cancer and Palliative Care Network | Health Support Services
Carers WA | Health Consumers' Council | Palliative Care WA


This publication is provided for education and information purposes only. It is not a substitute for professional medical care. Information about a therapy, service, product or treatment does not imply endorsement and is not intended to replace advice from your healthcare professional. Readers should note that over time currency and completeness of the information may change. All users should seek advice from a qualified healthcare professional for a diagnosis and answers to their medical questions.